INSURANCE FRAUD HANDBOOK

Transcription

1 INSURANCE FRAUD HANDBOOK

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3 2009 By the Association of Certified Fraud Examiners, Inc. No portion of this work may be reproduced or transmitted in any form or by any means electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system without the written permission of the Association. WORLD HEADQUARTERS, THE GREGOR BUILDING 716 WEST AVENUE AUSTIN, TX USA TEL: (800) (512) FAX: +1 (512) DISCLAIMER Every effort has been made to ensure that the contents of this publication are accurate and free from error. However, it is possible that errors exist, both typographical and in content. Therefore, the information provided herein should be used only as a guide and not as the only source of reference. The author, advisors, and publishers shall have neither liability nor responsibility to any person or entity with respect to any loss, damage, or injury caused or alleged to be caused directly or indirectly by any information contained in or omitted from this publication. Printed in the United States of America

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5 JAMES E. WHITAKER, CFE, CPP, PCI, CIFI President The Whitaker Group, LLC James E. Whitaker is the President and founder of the Whitaker Group, LLC, an investigative services and risk management consultant group headquartered in Ohio. As a retired police detective division commander; FBI National Academy graduate; Special Investigations Unit (SIU) Director and later a Claims Executive for a property and casualty insurance carrier; and Executive Director for the International Association of Arson Investigators, he has dealt extensively with insurance fraud in its many forms since He has a bachelor s degree in Criminal Justice Administration and a master s degree in Management (with an emphasis on Organizational Design), both attained from Myers University in Cleveland, Ohio. Mr. Whitaker has been a CFE since 1993 and is a Regent Emeritus as well as an adjunct faculty member for the ACFE. He has been a guest lecturer at ACFE Annual Conferences as well as ACFE Chapters in Cincinnati, Columbus, Cleveland, Pittsburgh, Philadelphia, Baltimore, and New Orleans. Mr. Whitaker is a Certified Insurance Fraud Investigator and serves on both the Investigation and Insurance Fraud Councils (Co-Chair) for ASIS International. He also serves as an adjunct faculty member for ASIS on the PCI (Professional Certified Investigator) review course faculty. Mr. Whitaker is a frequent lecturer on the topic of insurance fraud across the U.S. and serves as a consultant to various insurance companies on fraud related issues, employee training, and ethics program development.

11 Insurance Fraud Overview INSURANCE FRAUD OVERVIEW Introduction to Insurance Fraud The insurance business, by its very nature, is susceptible to fraud. Insurance is a risk distribution system that requires the accumulation of liquid assets in the form of reserve funds that are, in turn, available to pay loss claims. Insurance companies generate a large steady flow of cash through insurance premiums. Steady cash flow is an important economic resource that is very attractive and easily diverted. Large accumulations of liquid assets make insurance companies attractive for take over and loot schemes. Insurance companies are under great pressure to maximize the return on investing the reserve funds, thus making them vulnerable to high yielding investment schemes. This section will introduce you to some of the most common types of fraud involving the insurance industry. Agent/Broker Fraud Cash, Loan, and Dividend Checks A company employee without the knowledge of an insured or contract holder requests cash, a loan, or a dividend check, and deposits the check into either his bank account or a fictitious account. The employee, in order to minimize his chances of being detected committing a fraudulent act, might change the company policyholder s address of record to either his address or a fictitious address. Once the check is issued, the address is then changed back to the previous address. Settlement Checks A company employee can misdirect settlement checks, such as for a matured endowment settlement, to the branch office, their home, or a fictitious address. The employee can easily create a check defalcation by changing the address of record prior to the settlement check issue date, thus misdirecting the check in question. Also, an orphan contract holder might be transferred to his agency periodically, affording the opportunity to improperly request the issuance of a settlement check. An orphan contract holder is a policyholder or contract holder who has not been assigned to a servicing agent or the whereabouts of this individual is unknown. The servicing agent attempts to locate this family group and could influence them to purchase additional insurance. Insurance Fraud Handbook -1-

12 Insurance Fraud Overview Premium Fraud The agent collects the premium, but doesn t remit the check to the insurance company. The insured has no coverage. Fictitious Payees An agent or a clerk can change the beneficiary of record to a fictitious person and subsequently submit the necessary papers to authorize the issuance of a check. Fictitious Death Claims An agent or employee obtains a fictitious death certificate and requests that a death claim check be issued. The agent receives the check and cashes it. The sales representative can also write a fictitious application and, after the contestable period (two years), submit a phony death claim form and obtain the proceeds. The agent, by investing a few thousand dollars, could receive $50,000 or more in misappropriated claims. Underwriting Irregularities Equity Funding Equity funding is the process of using existing premium/policy values to finance new businesses. So long as the insured is aware of what is being done by the agent and fully understands the long range method of payment on the new contract, there is no apparent underwriting irregularity. Equity funding techniques, also known as piggybacking, usually do not produce quality business. Furthermore, the company increases the amount of life insurance on the books but receives little or no new funds while incurring increased sales and administrative expenses associated with the issue of that new business. Misrepresentation Misrepresentation might occur if a sales representative makes a false statement with the intent to deceive the prospective insured in order to knowingly obtain an unlawful gain. False Information A company employee might submit the following false information to obtain unlawful financial gain: Improper medical information to obtain a better insurable rate for the prospective policyholder -2- Insurance Fraud Handbook

13 Insurance Fraud Overview Improper date of birth to obtain a cheaper premium on the new policy Improper home address to obtain a cheaper premium for home or automobile insurance Improper driving history prior to purchasing automobile insurance to reduce the annual premium or obtain insurance where normally the individual would have to apply through the risk pool Fictitious Policies A salesman, in order to keep his position, submits fictitious policies to improve his writing record. Or, prior to an individual leaving the company, he writes fictitious policies called tombstone cases to improve his commission pool so that his compensation will be greater. Tombstone means an agent literally takes names from tombstones in a cemetery and writes new policies. Surety and Performance Bond Schemes Surety and performance bonds guarantee that certain events will or will not occur. An agent may issue worthless bonds to the insured for high-risk coverage in hopes that a claim is never made. If a claim is made, the agent might pay it off from agency funds, delay the payment, or skip town. Sliding Sliding is the term used for including additional coverages in the insurance policy without the knowledge of the insured. The extra charges are hidden in the total premium and, since the insured is unaware of the coverage, few claims are ever filed. For example, motor club memberships, accidental death, and travel accident coverages can usually be slipped into the policy without the knowledge of the insured. Twisting Twisting is the replacement, usually by high pressure sales techniques, of existing policies for new ones. The primary reason, of course, is for the agent to profit, since first-year sales commissions are much higher than commissions for existing policies. Churning Churning occurs when agents falsely tell customers that they can buy additional insurance for no cost by using built-up value in their current policies. In reality, the cost of the new policies frequently exceeds the value of the old ones. Insurance Fraud Handbook -3-

14 Insurance Fraud Overview Vehicle Insurance Schemes Ditching Ditching, also known as owner give-up, is getting rid of a vehicle to cash in on an insurance policy or to settle an outstanding loan. The vehicle is normally expensive and purchased with a small down payment. The vehicle is reported stolen, although in some cases, the owner just abandons the vehicle, hoping that it will be stolen, stripped for parts, or taken to a pound and destroyed. The scheme sometimes involves homeowner s insurance for the property that was stolen in the vehicle. Past Posting Past posting is a scheme in which a person becomes involved in an automobile accident, but doesn t have insurance. The person gets insurance, waits a little bit of time, reports the vehicle as being in an accident, and then collects for the damages. Vehicle Repair This scheme involves the billing of new parts on a vehicle when used parts were actually replaced in the vehicle. Sometimes this involves collusion between the adjuster and the body repair shop. Vehicle Smuggling This is a scheme that involves the purchase of a new vehicle with maximum financing. A counterfeit certificate of the vehicle s title is made showing that it is free and clear. The vehicle is insured to the maximum, with minimum deductible theft coverage. It is then shipped to a foreign port and reported stolen. The car is sold at its new location and insurance is also collected for the theft. Phantom Vehicles The certificate of title is a document that shows the legal ownership of a vehicle. Even though it is not absolute proof that a vehicle exists, it is the basis for the issuance of insurance policies. Collecting on a phantom vehicle has been shown to be easy to do. Staged Accidents Staged accidents are schemes in which an accident is predetermined to occur on a vehicle. The schemes are organized by rings and the culprits move from one area to another. They often use the same vehicle over and over, which is sometimes what causes their scheme to be uncovered. -4- Insurance Fraud Handbook

15 Insurance Fraud Overview Inflated Damages The business environment and competition for work in the automobile repair industry have caused the development of a scheme in which some establishments inflate estimated costs to cover deductibles. The insured is advised by the repair shop that the shop will accept whatever the company authorizes. Vehicle Identification Number (VIN)-Switch A VIN-switch is a fraud scheme in which a wrecked vehicle is sold and reported as being repaired. The vehicle is not actually repaired; instead, the VIN plate is switched with that of a stolen vehicle of the same make and model. Rental Car Fraud A person doesn t need to own a vehicle to commit automobile fraud. There are several schemes that can be perpetrated using rental cars. The most prevalent involve property damage, bodily injury, and export fraud. Property Schemes Property schemes usually involve the filing of insurance claims for property that never existed or for inflated loss amounts. Inflated Inventory Property that is lost through fire is claimed on an insurance form. However, property that doesn t exist also finds its way onto an inventory of the property claimed. Property claimed might have been previously sold or never owned by the claimant. Phony or Inflated Thefts A home or car that has been burglarized is the basis for filing a claim for recoveries of monies lost. However, as with items destroyed by fire above, the items never existed or were previously sold. Paper Boats A claim is filed for a boat that sank, but the boat never actually existed. It is not difficult to register a boat based on a bill of sale. After a period of time, a loss is claimed for the sinking of the boat. It is difficult to prove that the boat didn t exist or was sunk intentionally. Insurance Fraud Handbook -5-

16 Insurance Fraud Overview Arson for Profit Personal dwellings or commercial properties are destroyed by fire for the sole purpose of financial gain. Insureds may act alone or in concert with agents or highly organized crime rings specializing in arson. Life Insurance Schemes Fraudulent Death Claims To obtain reimbursement for life insurance, a death certificate is required. However, phony death certificates are not that difficult to obtain. The person might be very much alive and missing or the person might be dead, and the death is past posted. With small settlements, death claims aren t closely scrutinized and are paid relatively easily. Murder for Profit This scheme involves the killing (or arranging for the killing) of a person in order to collect insurance. The death might be made to look like it was an accident or a random killing. Liability Schemes In a liability scheme the claimant has claimed an injury that did not occur. The slip and fall scam is the most common, and involves a person claiming to fall as the result of negligence on behalf of the insured. Red Flags of Insurance Fraud Red flags of insurance fraud may include any of the following: The claim is made a short time after inception of the policy, or after an increase or change in the coverage under which the claim is made. This could include the purchase of a scheduled property or jewelry floater policy, or more than one during the time before the loss. The insured has a history of many insurance claims and losses. Before the incident, the insured asked his insurance agent hypothetical questions about coverage in the event of a loss similar to the actual claim. The insured is very pushy and insistent about a fast settlement, and exhibits more than the usual amount of knowledge about insurance coverage and claims procedures, particularly if the claim is not well documented. In a burglary loss, the claim includes large, bulky property that is unusual for a burglary. -6- Insurance Fraud Handbook

17 Insurance Fraud Overview In a theft or fire loss claim, the claim includes a lot of recently purchased, expensive property, or the insured insists that everything was the best or the most expensive model, especially if the insured cannot provide receipts, owner s manuals, or other documentary proof of purchase. In a fire loss claim, property considered personal or sentimental to the insured and that you would expect to see among the lost property (such as photographs, family heirlooms, or pets) is conspicuous by its absence. A large amount of the property was purchased at garage and yard sales and flea markets, or otherwise for cash, and there are no receipts (the insured will be unable to recall exactly where these sales took place or by whom). The insured cannot remember, or does not know, where he or she acquired the claimed property, especially unusual items, and/or he cannot provide adequate descriptions. On the other hand, the insured already has receipts and other documentation, witnesses, and duplicate photographs for everything; the claim is too perfect. Documentation provided by the insured is irregular or questionable, such as: Numbered receipts are from the same store and dated differently or sequentially. Documents show signs of alteration in dates, descriptions, or amounts. Photocopies of documents are provided and the insured cannot produce the originals. Handwriting or signatures are similar on different receipts, invoices, gift verifications, or appraisals. The amount of tax is wrong, either for the price of the property or for the date appearing on the receipt. Receipts, invoices, or shipping documents do not have paid, received, or other shipping stamps. In a theft or loss away from home, the insured waits an unusually long time before reporting the theft to the police. The insured is able to give the police a complete list of lost property on the day of the burglary or shortly after. The amount of the claim differs from the value given by the insured to the police. In a business inventory or income loss claim, the insured does not keep complete books, or the books do not follow accepted accounting principles. The physical evidence is inconsistent with the loss claimed by the insured. In a burglary loss, there is no physical evidence of breaking and entering, or a burglary could not have occurred unnoticed under the circumstances. In a fire loss: Insurance Fraud Handbook -7-

18 Insurance Fraud Overview The apparent cause and origin of the fire is inconsistent with an accidental cause and origin, or there is evidence of the use of an accelerant. The remains of the property do not match the claimed property. The premises do not show signs of having contained the claimed property, or the amount of property would not fit into the space where the insured says it was. Physical damage to the insured s car is inconsistent with its having been in a collision with an uninsured car. The insured has discarded the claimed damaged property before the adjuster can examine it. The cost of the claimed property, over the period of time it allegedly was acquired, seems to exceed the insured s financial ability to purchase it. The insured refuses or is unable to answer routine questions. The insured provides supporting evidence and documentation that cannot be corroborated. Information on a life application is very vague or ambiguous as to the details of health history, such as dates, places of treatment, names of physicians or hospitals, or specific diagnoses. Applicant fails to sign and date the application. Pertinent questions on the application are not answered, such as income, other insurance carried, hazardous duties, or aviation or flying activity. The insured has excess insurance, either shown at the time of application or developed through an underwriting report of database information. Earned income does not warrant the amount of insurance being applied for. The applicant s date of birth as shown on the application is much earlier than shown with other carriers or in previous applications or policies. The agent is putting on a great deal of pressure to have the policy issued because of the large amount applied for, but is going over the underwriter s head in order to do so (working out of the system). The physician s report is very vague on details of past medical history and does not coincide with the information shown on the application. A death claim is presented in which the death has taken place outside of the country. The signature on the application for insurance does not appear to be the same signature as shown on an authorization at the time of the claim. A claimant or a claimant s attorney attempts to limit the type of information to be related by a signed authorization, which is a standard authorization used by the company. An attorney is immediately brought into a contestable death claim, attempting to interfere with the investigation and to withhold information required by the company. -8- Insurance Fraud Handbook

19 Insurance Fraud Overview A contestable death claim is reported as an accidental death, but could possibly be a suicide (such as a fatal accident involving only one vehicle, a hunting accident, or an accidental shooting while cleaning or repairing a weapon). An autopsy report discloses a different height and weight than what is shown on the recent application (auto or house fire death). Dental records do not match the dental findings in the autopsy report. Records are missing on a patient who was confined to a hospital, or a patient s medical records are missing from the physician s office. The death claim package sent to the insurance company is too well packaged and complete in every detail with supportive documents. Documentation that was not initially asked for or required by the insurance company was voluntarily sent, such as newspaper reports, burial certificates, or shipment of the body from one country to another. The routine audit of a designated insured group shows a significant increase of added employees whose names do not show up on the payroll. Gunshot wounds or stabbings were inflicted by the insured as the aggressor or were self-inflicted. Police accident reports were submitted by the claimant. The claimant pushes for the claim to be handled quickly; for example, he wants to stop by the office to pick up his check as we re leaving for vacation in the morning. Series of prescription numbers from the same drug store don t coincide chronologically with the dates of the prescriptions. An automobile was destroyed by a fire in a very remote rural area with no witnesses; the driver claims an electrical shortage in the engine compartment caused the fire. Preliminary information for a business fire loss or home fire loss indicates considerable financial difficulties and financial pressures being brought upon the owner and the fire is suspicious in nature and/or origin. An employee within the claims operations of an insurance company is known to have a drinking or drug problem, financial pressures, serious marital difficulties, or an affair and irregularities start to appear. On burglary losses from a business or especially a home, the investigator observes that the remaining contents at the scene are of much inferior quality than those reported stolen. There is no indication of indentation in the piling of the carpet where heavy items of furniture or equipment were to have been placed. There are no hooks or nails on the walls where valuable pictures might have been hung. Entrances or exits are too small to take a large item through without laboriously disassembling it. Insurance Fraud Handbook -9-

20 Insurance Fraud Overview A claim contains false statements or it has been determined that there has been a deliberate coverup. A disability income protection claim is filed and it is determined that the claimant had recently purchased numerous expensive items on credit and had them all covered by credit A&H insurance coverage. Public transportation accidents in which there are more passenger claims filed than there were passengers at the time of the accident. A witness to an accident or incident deliberately tries to hide from investigators rather than come forth and tell the truth. An official document of findings is in complete conflict with the facts in the case and there is no explanation for this conflict of facts. Photographs or other documents do not substantiate the reported findings. Workers Compensation Fraud Workers compensation laws require employers or their insurance plans to reimburse employees (or on their behalf) for injuries that occurred on the job regardless of who is at fault and without delay of legal proceedings to determine fault. The injury may be physical, such as a broken limb, or mental, such as stress. Common Schemes Schemes are generally broken into four categories: premium fraud, agent fraud, claimant fraud, and organized fraud schemes. PREMIUM FRAUD This entails misrepresenting information to the insurer by employers to lower the cost of workers compensation premiums. AGENT FRAUD Agents issue certificates of coverage indicating the customer is insured, but never forward the premium to the insurance company. An agent may alter the application for coverage completed by the employer in order to be able to offer a lower premium to his client. CLAIMANT FRAUD Misrepresenting the circumstances of any injury or fabricating an injury Insurance Fraud Handbook

21 Insurance Fraud Overview ORGANIZED FRAUD Organized fraud schemes are composed of the united efforts of a lawyer, a capper, a doctor, and the claimant. This scheme is used not only in workers compensation cases, but also in other medical frauds, such as automobile injuries. THE LAWYER The lawyer is usually the organizer of the scheme and the one who will profit the most. The lawyer will entice the claimant into securing his services by promising a large settlement from the insurance company. The claimant may or may not have to undergo medical tests, since the only requirement of the claimant is that he be insured. The lawyer will then refer the injured party to a doctor for treatment. THE CAPPER A capper, also known as a runner, is used to recruit patients for the scheme. He may be employed by either the attorney or the doctor, and is paid, either a percentage of the total take or per person, for bringing in patients. THE DOCTOR The doctor may be one of the organizers or a player in the scheme, but must be a part of it in order for it to work properly. The doctor is used to lend authenticity to the scheme, and he is well compensated for his efforts. The doctor bills for services that he may or may not render as well as for unnecessary services. In addition, if the patient has regular health insurance, the doctor may double bill for the services. If the injury occurred as the result of an automobile accident while the patient was on the job, the doctor may bill all three insurance companies: the workers compensation carrier, the employee s health insurance, and the automobile carrier. Insurance Fraud Handbook -11-

22 Establishing and Measuring a New SIU ESTABLISHING AND MEASURING A NEW SPECIAL INVESTIGATION UNIT Introduction One of the most pressing issues facing modern day insurance carriers is the identification and investigation of fraud. With estimates ranging from $80 billion to $110 billion a year, insurance fraud is a growing concern within the industry. Current estimates show that 10 cents of every dollar earned is lost due to fraud. Since the late 1980s, most insurance carriers have been mandated by state statutes to both form and maintain an in-house SIU, or to contract those services out. That mandate is still being addressed today. Some companies that have maintained an internal SIU are now converting to outsourcing, while others that previously outsourced that function are now bringing the Special Investigation Unit inside. Since the growth of anti-fraud efforts began in earnest in the early 1990s, insurance companies have increasingly focused their efforts to determine the value that SIUs bring to a corporation. Through statistical measurement, insurers have sought to gauge the effectiveness of SIUs, calculate the returns on investments and determine whether SIUs should be expanded, reduced, taken in-house, or contracted out. Until recently, all of the individual efforts were largely unreported and certainly not in a central location. There was informal discussion, usually among executives, but nothing concrete that could be used as a benchmarking tool. SIUs were usually formed without the benefit of experience because SIUs were relatively new. There is now roughly twenty years of information from which to draw for the company that is revamping or newly instituting their Special Investigation Unit. A company that is thinking about converting from an outsourced SIU function, or starting a new SIU from scratch, has many issues to consider. Among these issues are: Compliance with state department of insurance mandates. Compliance with state statutes governing the existence and operation of SIUs. How to begin the planning and staffing process. What are the selection criteria for potential SIU candidates? Who measures the results of the SIU effort? What is the frequency of measurement? Who verifies or refutes the accuracy of the measurement? Should calculated savings be measured? If so, what method should be used? -12- Insurance Fraud Handbook

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